Provider Demographics
NPI:1619386430
Name:HEITZIG, AMY LYNN (PTA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LYNN
Last Name:HEITZIG
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 W BRIDGEPORT ST
Mailing Address - Street 2:
Mailing Address - City:WHITE HALL
Mailing Address - State:IL
Mailing Address - Zip Code:62092-1001
Mailing Address - Country:US
Mailing Address - Phone:217-374-2144
Mailing Address - Fax:
Practice Address - Street 1:620 W BRIDGEPORT ST
Practice Address - Street 2:
Practice Address - City:WHITE HALL
Practice Address - State:IL
Practice Address - Zip Code:62092-1001
Practice Address - Country:US
Practice Address - Phone:217-374-2144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2018-12-04
Deactivation Date:2018-03-02
Deactivation Code:
Reactivation Date:2018-09-19
Provider Licenses
StateLicense IDTaxonomies
MO2014037473225200000X
IL160.001512225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant